Br J Sports Med 2000;34:79–85 79

Leaders

Br J Sports Med: first published as 10.1136/bjsm.34.2.81 on 1 April 2000. Downloaded from http://bjsm.bmj.com/ on October 11, 2019 by guest. Protected by copyright.
Snowboarding injuries

Since the inception of the idea of riding a board on the er’s talus fractures, are problematic and continue to be
snow in the 1970s, the popularity of the winter sport of underdiagnosed and under-reported. Any acute and/or
snowboarding has burgeoned. Snowboarding is the only persistent anterolateral ankle pain in a snowboarder should
area of the winter sports market that has continued to grow. be considered a talus fracture until proven otherwise. Most
The 1994–1995 NSAA Kottke National Business Survey of these fractures are not able to be diagnosed by plain
indicated that 14% of the 54 million area visits in the radiographs and require computed tomography imaging
United States were generated by snowboarders.1 It has for definitive diagnosis. Most snowboarder’s talus fractures
been reported that 80% of children who participate in need operative treatment with excision of fracture
snow sports have ridden snowboards by their 12th fragments or internal fixation of the fractures.
birthday.2 Industry analysts project that by the early 2000s With the continued growth of snowboarding it will be
more than 40% of those on the slopes will be snowboard- increasingly more important for practitioners to be famil-
ers. iar with the diagnosis and treatment of snowboarding
With the rise in popularity of snowboarding there has injuries. The studies have resulted in identifying and
been a change in the injury pattern of these winter sports defining of a spectrum of injuries diVerent from those of
participants as compared with skiing. There has also been alpine skiing. Now that the spectrum of snowboarding
the recognition of an ankle injury that is specific to and injuries has been identified, the challenge will not only be
only occurs in snowboarding. Along with a number of the appropriate treatment of such injuries but also educa-
other medical facilities in Colorado, our clinic participated tion about, research into, and prevention of such injuries.
in a 10 year survey of snowboarding injuries (1988–1999). This will not only be the responsibility of the health care
A total of 7430 snowboarding related injuries were seen in provider but also that of manufacturers, ski area owners
7051 patients; 74.1% of those injured were male and and developers, snowboard shops, as well as snowboarders
25.9% were female. Of the injured snowboarders, 45.2% themselves.
were beginners, 31.4% intermediate, and 23.4% expert. THOMAS P MOORE
There were significantly more upper extremity injuries Rocky Mountain Sports Medicine and Orthopedic Clinic, Crested Butte
than with skiing, which accounted for 49.1% of all and Basalt, Colorado, USA
injuries.
Ankle injuries accounted for 12% of all injuries, and 1 SnowSports Industries America National Snowboarder Survey. McLean,
Virginia: SnowSports Industries America, 1995 and 1996.
fractures of the lateral process of the talus fractures 2 Meyers C. On the edge: new riders on the Olympic stage. Ski Magazine
accounted for 3%. Lateral process fractures, or snowboard- 1996;25:25.

“You don’t have to . . .”: walking to a healthier nation

One of the best pieces of public health news in recent years as “real” exercise, there being a belief that to be beneficial
has been that you do not have to be a marathon runner, exercise has to make people sweaty and out of breath.
sports champion, or even regular jogger to derive substan- Also, there were negative “non-aspirational” perceptions
tial health benefits through exercise: regular moderate of walking, including (older) age profile, low status as
physical activity has cardioprotective and other health a form of transport, and a boring image. Further
benefits.1 From this and our low levels of exercise as a developmental research pointed to the value of giving
population, it can reasonably be concluded that promoting people “surprising” information about the value of
regular moderate physical activity—active living—is not walking.
only the most feasible route for exercise promotion but A few years on, if you ask people what they think of
also the one that will yield the largest population health when they hear of “HEBS”, their answer will probably
gain.2 include the name “Gavin”. They are referring to the TV
HEBS (the Health Education Board for Scotland) has advertising campaign that arose from the developmental
been something of a pioneer of the active living approach research. Paradoxically using a sporting hero to promote
in the United Kingdom.2–4 We place a strong emphasis on regular moderate activity, the advertisement features
walking because of its accessibility. Walking is easy for Gavin Hastings comparing walking a mile with energy
most people to contemplate and do, regardless of age or equivalent amounts of vigorous exercise. He points out
fitness level. It does not require special skills, expensive that “you don’t have to” take part in sweaty, frenetic, or
equipment, or facilities. It can be built into everyday life— very demanding forms of exercise to gain health and
for example, in commuting, shopping, and leisure. And fitness benefits; in essence you can walk to good health. In
the risk of injury is generally low.5 HEBS commissioned the first phase of running the advert on TV, it was backed
qualitative research conducted in 1995 supported this up by a special telephone helpline oVering a pack contain-
notion of accessibility, with preference being shown for ing the HEBS self help guide Hassle free exercise and infor-
walking over swimming or dancing. The same research, mation on local level physical activity facilities and
however, suggested that walking was not generally viewed contacts.
80 Leaders

Formal evaluation of the first phase of the campaign is In evaluation we therefore need to tap into “captive
reported in detail elsewhere.6 Campaign awareness and populations” (such as helpline callers) where they exist,

Br J Sports Med: first published as 10.1136/bjsm.34.2.81 on 1 April 2000. Downloaded from http://bjsm.bmj.com/ on October 11, 2019 by guest. Protected by copyright.
walking related knowledge and beliefs were monitored and to manage potential bias through study design and
through adult population surveys. Self reported changes in analysis.
physical activity levels were assessed through a panel study In any case, Gavin, with repeated showings, has
involving a sample (initially 700) drawn from the 4036 undoubtedly caught the attention of the people of
people who had called the helpline during its first six Scotland. Awareness of the advertisement in the adult gen-
weeks. A composite measure of “stage of change” (precon- eral population runs consistently at around 90%, and I
templation, contemplation, preparation, action, mainte- have referred to its centrality to people’s awareness of
nance) was derived from information provided by helpline HEBS. In 1997 Gavin was voted favourite advertisement in
callers at baseline and follow up.7 The rate of successful a readers’ poll conducted by The Scottish Sun as part of the
follow up at one year in the panel study was 58%. The Scottish Advertising Awards. This is no mean feat, and its
sociodemographic profile of respondents at one year was significance in evaluation terms should not be underesti-
similar to that at baseline, except for a slightly higher attri- mated. It is evidence that health education advertising can
tion rate for younger people. have a wide appeal and become part of the fabric of the
Campaign awareness was highest in the primary target nation, more than holding its own with more expensive and
group (socioeconomic groups C2DE). There was before/ less socially useful advertising.
after evidence of an impact on the general adult The campaign and other health education eVorts—in
population’s knowledge and beliefs about walking as a schools, through the workplace and health service, and in
form of exercise, the biggest increase being in knowledge other settings—are of course but pieces in a jigsaw of fac-
of exercise equivalence information specific to the tors aVecting the nation’s levels of activity. Policies and
campaign. This is evidence of success of the major action in areas such as community safety, transport, pollu-
campaign objective of “repositioning” walking in the tion control, urban and rural planning, and access to facili-
minds of the public. Also, in the panel study there was a ties are needed to make it more appealing and more feasi-
discernible shift in stage of change (in the right direction) ble for people to build physical activity into their everyday
between baseline and follow up. Furthermore, 48% of the lives at all stages and ages.
helpline callers successfully contacted at one year reported ANDREW TANNAHILL
being more active. Chief Executive, Health Education Board for Scotland
The panel study of helpline callers was of course poten- Woodburn House, Canaan Lane
tially open to initial self selection bias, and to subsequent Edinburgh EH10 4SG, Scotland
drop out and “desire to please” bias. Suppose for the sake
of argument that almost 2000 people (48% of 4036) were 1 Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a rec-
ommendation from the Centers for Disease Control and Prevention and
motivated and helped to become more active through the the American College of Sports Medicine. JAMA 1995;273:402–7.
advertisement and helpline. Even in the absence of any 2 Wimbush E. A moderate approach to promoting physical activity: the
evidence and implications. Health Education Journal 1994;53:322–36.
such eVect on people who viewed the advert but did not 3 HEBS. Promoting physical activity in Scotland: a policy statement. Edinburgh:
call the helpline—and disregarding the important inform- Health Education Board for Scotland, 1995.
4 HEBS. The promotion of physical activity in Scotland: a strategic statement.
ing and agenda setting roles of the campaign—this would Edinburgh: Health Education Board for Scotland, 1997.
be a worthwhile outcome and indeed would represent 5 Davison RCR, Grant S. Is walking suYcient exercise for health? Sports Med
1993;16:369–73.
good value for money. However, this amount of 6 Wimbush E, MacGregor A, Fraser E. The impacts of a national mass media
behavioural change would not be detectable even in campaign on walking. Health Promotion International 1998;13:45–53.
7 Buxton K, Wyse J, Mercer T. How applicable is the stage of change model
a fairly substantial survey of the general population. to exercise behaviour? A review. Health Education Journal 1996;55:239–57.

Role of exercise counselling in health promotion

Despite the clear health benefits that can be attained health care fields, the potential public health impact that
through adopting a more active lifestyle, most adults in the primary care settings can have on health behaviour
United Kingdom as well as other industrial nations remain change, including physical activity, merits continued
underactive. Faced with this epidemic, there is a growing investigation.
need for physical activity interventions that can be widely Although a relatively large body of research exists on
disseminated to all segments of the population across the advice and counselling by doctors for other health behav-
lifespan. iours, such as smoking, relatively little systematic research
One promising avenue for physical activity counselling has been conducted to date on physical activity promotion
and support lies with the primary care doctor and other in primary care. The studies that have been undertaken
health care professionals. The strengths of incorporating have taken advantage of a growing body of knowledge,
physical activity advice and support as part of routine underscoring the utility of applying empirically supported
health care include the ability to reach a substantial behavioural strategies in facilitating physical activity
portion of the population repeatedly over time, the change. Such behavioural strategies, derived primarily
consistency and continuity of message content and from social cognitive theory and its derivatives, include:
delivery, and the willingness among patients to act on their identifying specific practical physical activity goals tailored
doctor’s advice.1 2 Despite these strengths, however, a to the patient’s needs and circumstances; structuring ini-
number of barriers to physical activity counselling in tial patient expectations so that they are realistic; identify-
primary care have been documented, including lack of ing those benefits related to becoming more physically
time, reimbursement, and training in physical activity or active that are most germane to the patient’s own health
behaviour change counselling.3 Although such barriers status; encouraging the patient to keep track of his or her
present continuing challenges to the health promotion and own physical activity patterns through simple self
Leaders 81

monitoring tools; and providing continual interest, shown to be eVective in both older and younger adult
encouragement, and support for physical activity. Some of populations, women as well as men, cardiac patients, older

Br J Sports Med: first published as 10.1136/bjsm.34.2.81 on 1 April 2000. Downloaded from http://bjsm.bmj.com/ on October 11, 2019 by guest. Protected by copyright.
these behavioural strategies have been used in studies in family carers of relatives with dementia, and overweight
which primary care doctors have been trained to deliver patients. It has been found to be eVective in promoting
brief advice and counselling on physical activity, with physical activity of various types—for example, endurance,
encouraging results in the short term.4 5 In one study, for strength, flexibility, general conditioning—intensities—for
example, a written goal oriented exercise prescription example, moderate intensity exercise, more vigorous
from general practitioners, in addition to verbal advice, exercise—and formats—for example, home based, group
was particularly eVective in promoting increased physical based, combinations of home based and group based exer-
activity over a six week period.6 More discrepant results cise. Telephone and similar mediated approaches allow
obtained from longer term multiple risk factor pro- both the health professional and the patient a level of con-
grammes, however, suggest that more intensive interven- venience and flexibility that is often diminished or lacking
tions may be needed to obtain longer term eVects in at in group based physical activity regimens.
least some segments of the population. Such interventions In summary, to reach the public health goals on physical
could include the use of health educators and profession- activity in the United Kingdom, United States, Australia,
als in addition to the doctor. Health educators and other and other countries continued eVorts to involve primary
allied health professionals can provide a level of advice and care providers and other health professionals as active
counselling beyond that which doctors, constrained by facilitators of the physical activity message are strongly
time and similar barriers, are typically able to deliver.7 One indicated. Primary care advice in conjunction with referral
promising approach awaiting more extensive investigation to appropriate community organisations may help to facili-
involves using brief advice from the doctor as a means of tate the long term increases in physical activity participa-
setting the stage for physical activity change in conjunc- tion that are critical for health promotion and disease pre-
tion with specific referral to other health care based or vention. Telephone and other mediated approaches to
community based health educators or providers. In this physical activity promotion provide a promising avenue for
way, the perceived credibility and authority of the doctor programme delivery, in primary care as well as other com-
can be harnessed as a catalyst for change, while the very munity settings.
real time constraints facing many doctors are recognised.8 ABBY C KING
The challenge remains to structure the referral network Stanford University School of Medicine
eVectively such that patients will successfully follow Palo Alto
through with the referral. To maximise the potential ben- CA 94304-1583, USA
efits of this type of referral network, continuing communi-
cation between the doctor and referral source is essential. 1 Williford HN, Barfield BR, Lazenby RB, et al. A survey of physicians’
attitudes and practices related to exercise promotion. Prev Med
In addition, the studies targeting primary care providers 1992;21:630–6.
have focused almost exclusively on doctors involved in 2 Goldstein MG, DePue J, Kazura A, et al. Models for provider-patient
ineraction: applications to health behavior. In: Shumaker SA, Schron SB,
family practice and internal medicine. Yet, other primary Ockene JK, et al, eds. The handbook of health behavior change, 2nd ed. New
care specialties, such as paediatrics and obstetrics- York: Springer, 1998:85–113.
3 Pender NH, Sallis JF, Long BJ, et al. Health care provider counseling to pro-
gynaecology, reach important segments of the population mote physical activity. In: Dishman RK, ed. Exercise adherence, 2nd ed.
for whom physical activity information and messages are Champaign, IL: Human Kinetics, 1994:213–35.
4 Calfas KJ, Long BJ, Sallis JF, et al. A controlled trial of physician counseling
particularly relevant. Future research should target the full to promote the adoption of physical activity. Prev Med 1996;25:225–33.
range of primary care practice. 5 Marcus BH, Goldstein MG, Jette A, et al. Training physicians to conduct
physical activity counseling. Prev Med 1997;26:382–8.
While face to face instruction and counselling for physi- 6 Swinburn BA, Walter LG, Arroll B, et al. The green prescription study: a
cal activity have traditionally been the norm in most coun- randomized controlled trial of written exercise advice provided by general
practitioners. Am J Public Health 1998;88:288–91.
tries, a growing scientific literature has underscored the 7 King AC, Sallis JF, Dunn AL, et al. Overview of the activity counseling trial
utility of mediated channels for delivering physical activity (ACT) intervention for promoting physical activity in primary care settings.
Med Sci Sports Exerc 1998;30:1086–96.
advice and information in an eYcient, eVective, and 8 Stevens W, Hillsdon M, Thorogood M, et al. The cost eVectiveness of a
potentially less costly fashion. For instance, in the United primary care-based physical activity intervention in 45–74 year old men
and women: a randomised controlled trial. Br J Sports Med 1998;32:236–
States, at least 13 randomised controlled investigations 41.
have systematically evaluated the use of telephone based 9 DeBusk RF, Haskell WL, Miller NH, et al. Medically directed at-home
rehabilitation soon after clinically uncomplicated acute myocardial
physical activity advice and support, either in conjunction infarction: a new model for patient care. Am J Cardiol 1985;55:251–7.
with or independent of advice from the doctor.7 9 10 The 10 King AC, Rejeski WJ, Buchner DM. Physical activity interventions targeting
older adults: a critical review and recommendations. Am J Prev Med 1998;
telephone supervised physical activity approach has been 15:316–33.

Where is the pain coming from in tendinopathy? It may be

biochemical, not only structural, in origin

Traditional dogma would have it that pain in tendinopathy inconsistent with either theory. Consider first the inflam-
arises through one of two mechanisms. Firstly, it may result mation mechanism. Histopathological examination of sur-
from inflammation in “tendinitis”. Secondly, it may be due gical specimens from patients with chronic tendon pain are
to separation of collagen fibres in more severe forms of devoid of inflammatory cells.1 This applies to tissue from
tendinopathy. The latter situation parallels the mechanism the Achilles, patellar, lateral elbow, medial elbow, and rota-
of pain with collagen separation after an acute grade I or II tor cuV tendons. Furthermore, prostaglandin E2 (a marker
ligament injury (fig 1). of the inflammatory process) is no more abundant in
Despite the wide acceptance of these two classical mod- patients with Achilles tendon pain than in normal
els of pain production, a number of studies provide data controls.2
82 Leaders

Unfortunately, the collagen separation theory does jumper’s knee, this fat tissue contained increased Alcian
not hold up under scrutiny either. The following five blue stain (and thus glycosaminoglycans), presumably

Br J Sports Med: first published as 10.1136/bjsm.34.2.81 on 1 April 2000. Downloaded from http://bjsm.bmj.com/ on October 11, 2019 by guest. Protected by copyright.
observations about pain and collagen in the patellar leaked from the adjacent region of tendinosis.
tendon are inexplicable. (a) Patients who have patellar To our knowledge, the key irritant biochemical
tendon allograft anterior cruciate ligament reconstruction agent has not yet been identified, and this presents a
have minimal donor site knee pain, yet collagen has been challenge for tendon biochemists. Using microdialysis,
excised. (b) Such patients are generally pain-free (and Alfredson recently identified an abnormal amount of the
back at sport) despite the persistence of abnormal excitatory neurotransmitter, glutamate, in subjects with
collagen for two or more years.3 4 (c) Similarly, after painful Achilles tendinopathy.2 Until these histopatho-
open surgery for jumper’s knee, the imaging appearance logical and biochemical findings are correlated with
of the tendon—that is, collagen status—does not some measure of pain, we can only speculate as to whether
correlate consistently with knee pain.5 (d) Patients with they are causative, or merely byproducts of nearby tendi-
jumper’s knee can also be treated by an arthroscopic nosis.
debridement of the infrapatellar fat pad and the Of interest, in the rotator cuV pain and pathology study
posterior border of the patellar tendon without operation quoted above,9 collagen damage was inversely related to
on the collagen defect in the tendon itself.6 (e) Large pain, but the presence of substance P (a nociceptive neuro-
asymptomatic ultrasonographic hypoechoic regions transmitter) was significantly associated with pain. Nerve
(abnormal collagen) can be found in patellar tendons of fibres immunoreactive to substance P were localised
some athletes who have never had a history of jumper’s around vessels in the subacromial bursa and in the
knee.7 8 non-perforated rotator cuV.9
Such discrepancy between collagen structure and pain Although the data presented may suggest a biochemical
is not confined to the patellar tendon. Patients with cause of pain, other workers consider mechanical
partial (non-perforated) rotator cuV tears were found to impingement of the fat pad as a cause of anterior knee
have more pain than those with complete perforations9 pain. The Australian physiotherapist, Jenny McConnell,
despite the former having less collagen damage. Clearly
recognised fat pad impingement as a cause of anterior
there is more to tendon pain than discontinuity of collagen
knee pain (not necessarily tendon pain) over 10 years ago.
per se.
Johnson proposed that impingement caused the pain of
Nociceptors provide significant aVerent pain pathways.
patellar tendinopathy.14 The infrapatellar fat pad is an
In the knee, they are located in the retinaculum, fat pad,
extremely sensitive region15 and contains a large number
synovium, and periosteum,10 and all these structures may
play a role in the tendon pain pathway. Biochemical of nociceptors, but as tendon pain occurs at many
irritants may include extravasation of glycosamines, anatomical sites, it does not appear logical that a structure
especially chondroitin sulphate,11 12 from damaged related to only one tendon—that is, the patellar fat pad—
tendon. would necessarily play a unique role in a problem as
The five observations listed above can be explained with widespread as tendinopathy. Further, the clinical
what we term a “biochemical” hypothesis (fig 2). We observation that the pain of jumper’s knee does not
speculate that the pain of patellar tendinopathy is largely disappear and may actually increase when palpation is
due to biochemical agents irritating nociceptors located in performed with the knee in full extension would appear to
the fat pad immediately posterior to the patellar tendon. In argue more for a biochemical than a mechanical cause of
39 cadaver dissections of the proximal patellar tendon,13 we pain in tendinopathy. Nevertheless, the jury requires more
consistently identified a thin layer of fat adherent to the evidence.
posterior portion of the patellar tendon. In the correspond- If our biochemical hypothesis proves to have some valid-
ing tissue specimens from patients operated on for chronic ity, it would have significant clinical and research implica-
tions. In clinical management, the aim of treatment would
be to modify the biochemical milieu, rather than to focus
Inflammation Collagen separation
on reducing inflammation or necessarily augmenting colla-
("tendinitis") (tendinosis, partial tears)
gen repair. Collagen repair may, of course, improve the
biochemical milieu and thus explain why eccentric
Pain fibres mainly within tendon collagen
strengthening programmes can help.16 Researchers would
be encouraged to pursue a pharmaceutical approach
Implication focused on reducing the irritant (but not necessarily
Tendon repair is required to decrease pain inflammatory) biochemical compounds around the ten-
don. Surgery may play a role through denervation. Thus, if
Figure 1 The classical “inflammatory” and “structural” tendon pain
models. sports medicine researchers collaborate with basic scien-
tists who understand pain physiology, knowledge will be

As yet unidentified biochemical noxious compounds (candidates include

matrix substances such as chondroitin sulphate)

Significant pain fibres in surrounding synovium and tissues,

as well as in tendon substance

Implications
1. Tendon repair is one method to decrease biochemical toxins and
thus pain
2. Pharmaceutical antidote to biochemical toxins would decrease pain
3. Denervation of nociceptors—that is, certain surgery—would decrease
pain

Figure 2 Contemporary “biochemical” tendon pain model.

Leaders 83

advanced in both fields, and we will progress toward the 5 Khan KM, Visentini PJ, Kiss ZS, et al. Correlation of US and MR imaging
with clinical outcome after open patellar tenotomy: prospective and retro-
goal of alleviating the pain of what is often structurally

Br J Sports Med: first published as 10.1136/bjsm.34.2.81 on 1 April 2000. Downloaded from http://bjsm.bmj.com/ on October 11, 2019 by guest. Protected by copyright.
spective studies. Clin J Sport Med 1999;9:129–37.
rather a trivial problem. 6 Coleman BD, Khan KM, Kiss ZS, et al. Outcomes of open and arthroscopic
patellar tenotomy for chronic patellar tendinopathy: a retrospective study.
K M KHAN Am J Sports Med 2000;28:183–90.
School of Human Kinetics and Allan McGavin Sports Medicine Centre 7 Cook JL, Khan KM, Harcourt PR, et al. Patellar tendon ultrasonography in
University of British Columbia asymptomatic active athletes reveals hypoechoic regions: a study of 320
tendons. Clin J Sport Med 1998;8:73–7.
Vancouver, Canada 8 Lian O, Holen KJ, Engebrestson L, et al. Relationship between symptoms of
J L COOK jumper’s knee and the ultrasound characteristics of the patellar tendon
among high level male volleyball players. Scand J Med Sci Sports
Victorian Institute of Sport Tendon Study Group and Alphington Sports 1996;6:291–6.
Medicine Clinic, Melbourne, Australia 9 Gotoh M, Hamada K, Yamakawa H, et al. Increased substance P in subac-
romial bursa and shoulder pain in rotator cuV diseases. J Orthop Res 1998;
N MAFFULLI 16:618–21.
Department of Orthopaedics 10 Witonski D, Wagrowska-Danielewicz M. Distribution of substance-P nerve
University of Aberdeen fibres in the knee joint in patients with anterior knee pain syndrome. A pre-
Aberdeen, Scotland liminary report. Knee Surg Sports Traumatol Arthrosc 1999;7:177–83.
11 Benazzo F, Stennardo G, Valli M. Achilles and patellar tendinopathies in
P KANNUS athletes: pathogenesis and surgical treatment. Bull Hosp Jt Dis 1996;54:
UKK Institute, Tampere, Finland 236–40.
12 Józsa L, Kannus P. Human tendons. Champaign, IL: Human Kinetics, 1997:
576.
1 Khan KM, Cook JL, Bonar F, et al. Histopathology of common overuse ten- 13 Khan KM, Bonar F, Desmond PM, et al. Patellar tendinosis (jumper’s
don conditions: update and implications for clinical management. Sports
Med 1999;27:393–408. knee): findings at histopathologic examination, US and MR imaging. Radi-
2 Alfredson H. In situ microdialysis in tendon tissue: high levels of glutamate, ology 1996;200:821–7.
but not prostaglandin E2 in chronic achilles tendon pain. Knee Surg Sports 14 Johnson DP. Magnetic resonance imaging of patellar tendonitis. J Bone Joint
Traumatol Arthrosc 1999;7:378–81. Surg [Br] 1996;78:452–7.
3 Adriani E, Mariani PP, Maresca G, et al. Healing of the patellar tendon after 15 Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the
harvesting of its mid-third for anterior cruciate ligament reconstruction and internal structures of the human knee without intra-articular anesthesia.
evolution of the unclosed donor site defect. Knee Surg Sports Traumatol Am J Sports Med 1998;26:773–7.
Arthrosc 1995;3:138–43. 16 Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle
4 Kiss ZS, Kellaway D, Cook J, et al. Postoperative patellar tendon healing: an training for the treatment of chronic Achilles tendinosis. Am J Sports Med
ultrasound study. Australas Radiol 1998;42:28–32. 1998;26:360–6.

~ O2 slow component and performance in endurance sports

V

For almost 80 years, physiological studies have attempted monoexponential increase in V ~ O2, there is a second
to explain endurance performance and to develop ways of increase after about three minutes which is defined as the
improving it by training. Performance for a runner can be ~ O2 slow component. V
V ~ O2 reaches a delayed steady state
represented by the relation of his/her personal power which is higher than the V ~ O2 requirement estimated from
(velocity) to time to exhaustion (time limit).1 the relation between V ~ O2 and moderate work rate. For
There are particular velocities that delineate intensity instance, in this case the athlete can run at 90% vV ~ O2MAX
domains which are determined by oxygen uptake (V ~ O 2) and reaches and stabilises at 95% V ~ O2MAX at the sixth
and blood lactate response versus time.2 3 We are going minute of exercise (time to exhaustion at this velocity being
to use them to define the slow phase of V ~O2 kinetics V ~ O2 about 10–15 minutes). This corresponds to the so called
slow component) which only appears during intense “critical power” which is the vertical asymptote of the
exercise. hyperbolic relation between power (velocity) and time.6
A high range of work can be identified at which there is Time limit at the critical velocity is reduced to less than 30
a sustained increase in blood lactate and a decrease in minutes because of rapid glycogen depletion.7 8 The critical
arterial pH with time. These responses decline back velocity is the highest velocity below its maximal level
towards a baseline value. Oxygen uptake increases in a (V~ O2MAX) at which oxygen consumption can reach a steady
monoexponential way and stabilises at about 80% in high state.
level marathon runners for at least an hour and a half Above this critical velocity, during high intensity
of continuous exercise. After that time, it is possible for exercise, neither V ~ O2 nor blood lactate can be stabilised,
oxygen consumption to increase because of thermo- and both rise inexorably until fatigue ensues, at which
regulatory constraints, and this increase is called the “V ~ O2 point V~ O2 reaches its maximum value.9
drift”. This intensity of exercise corresponds to the veloc- The initial very small component (phase 1), resulting
ity that can be sustained during a marathon and is equal to from a sudden change in the venous return in combination
about 80% of the velocity associated with V ~ O2MAX with a small change in the mixed venous gas tension, is not
determined in an incremental test—that is, vV ~ O2MAX.4 fitted into the following equation. In fact, the parameters
During this type of exercise both lipids and carbohydrate for the oxygen uptake kinetics were obtained from a two
are used as fuel. component exponential model in which the first compo-
At a higher intensity, the maximal lactate steady state nent accounted for the fast component (phase 2) and the
occurs5 when the rate of appearance of blood lactate equals second component accounted for the slow component
~ O2 stabilises after three min-
the rate of its disappearance. V (phase 3). The oxygen uptake kinetics are described as a
utes at about 85% V ~ O2MAX. This corresponds to the high- function of time by the following equation10: V ~ O2 (t) = A0
est velocity that an athlete can sustain for an hour (85% (baseline) + A1 (1−e−(tTD1)/ô1) (fast component) + A2
vV~ O2MAX for a well trained endurance athlete); carbohy- (1−e−(tTD2)/ô2)] (slow component)
drate (and lactate even) is the main substrate for this exer- where A0 is the resting baseline value, A1 and A2 are the
cise. amplitudes for the two components, ô1 and ô 2 are the time
At a higher intensity, at about 90% vV ~ O2MAX, the rate of constants for the two components, and TD1 and TD2 are
appearance of blood lactate exceeds the rate of disappear- the time delays from the onset of exercise for the two com-
ance and therefore blood lactate increases. After the first ponents.
84 Leaders

Hence, the so called V ~ O2 slow component is the second tinuous exercise, the critical velocity at V ~ O2MAX can be
amplitude (A2) of the increase in V ~ O2 that appears at TD2. determined using the critical power model. Instead of total

Br J Sports Med: first published as 10.1136/bjsm.34.2.81 on 1 April 2000. Downloaded from http://bjsm.bmj.com/ on October 11, 2019 by guest. Protected by copyright.
This second amplitude represents about 10% of the first time limit run, only the time run at V ~ O2MAX is plotted
(A1) and depends on the absolute intensity of exercise against the distance run at V ~ O2MAX. The slope of this plot
because V ~ O2 is regulated by the split of ATP and is the critical velocity at V~ O2MAX. This relation between
phosphocreatine.11 The value of the V ~ O2 slow component tlimV~ O2MAX and velocity can be used to determine the
can reach 500 ml/min and is generally considered to be velocity that elicits the longest time to exhaustion at
significant when the value is above 200 ml/min. To avoid ~ O2MAX.26 27 This velocity is not significantly diVerent from
V
the use of this complicated equation which necessitates the vV~ O2MAX determined from an incremental protocol, but is
use of software such as Sigma plot (SPSS), the V ~ O2 slow significantly higher than the critical velocity classically
component can be identified as described initially by determined using a two parameter critical power model
Whipp and Wasserman12 by calculating the diVerence in and the total distance-time.26
~ O2 measurement between the 6th and 3rd minute or, if the
V The existence of this V~ O2 slow component phenomenon
exercise is performed until exhaustion, between the third raises the question of how athletes can adapt their training
and last minute.13 to improve performance. In fit runners, who are not
The appearance of this slow V ~ O2 component is mainly at a high level (vV ~ O2MAX = 19 km/h), eight weeks of
due to the recruitment of fast fibre type II fibres with training at high intensity was shown to remove the
fatigue.14 It has been shown that type II fibres have a ~ O2 slow component at the same absolute velocity
V
phosphate to oxygen ratio that is 18% lower than in type I (V Billat, A Demarle, J Slawinski and JP Koralsztein,
fibres, probably because of a greater reliance on the unpublished work). This was because vV ~ O2MAX increased,
á-glycerophosphate shuttle than the malate-aspartate and at the same velocity was at a lower percentage of
shuttle.15 Therefore more oxygen is required to produce vV~ O2MAX than before training. The time limit at this previ-
the same level of ATP turnover and sustain a given power ously high intensity training was doubled (20 v 10
output. The other 15% is due to an increase in cardiac and minutes). At the same relative velocity to vV ~ O2MAX, the V
~ O2
ventilation work. Training decreases the V ~ O2 slow compo- slow component was comparable with that before
nent at the same absolute velocity, mainly because of an training, which means that this high intensity training
increase in the distribution of type I fibres and an increase (twice a week) has to be calibrated at least every two
in mitochondrial and capillary density.16 17 A decrease in months in this case.
the V ~ O2 slow component can also appear for the same In conclusion, the V ~ O2 slow component phenomenon,
relative velocity (in % vV ~ O2MAX) because of an increase in which was first described by Margaria et al in the sixties28
the maximal lactate steady state.18 However, during and then by Whipp and Wasserman in the seventies,12 has
intense exercise, the amplitude of the V ~ O2 slow component been widely focused on in the nineties. In the light of this,
is not linked to endurance at all. Moreover, it has been it should be possible in the next five years to use the
reported that triathletes that had no V ~ O2 slow component knowledge to diversify training and to explore endurance
in running compared with cycling had the same training eVects and fitness.
endurance time in these two types of exercise (at 90% of VÉRONIQUE L BILLAT
the power or velocity associated with V ~ O2MAX). These tria- University Lille 2, Centre de médecine du sport CCAS
thletes also had the same maximal lactate steady state at 75010 Paris, France
82% of velocity or power associated with V ~ O2MAX in run-
ning and cycling. 1 Billat V, Koralsztein JP, Morton H. Time in human endurance models. From
Endurance training decreases the V ~ O2 slow component empirical to physiological models. Sports Med 1999;27:359–79.
2 Whipp, BJ. The slow component of O2 uptake kinetics during heavy
at the same velocity.19–22 Personal data on high intensity exercise. Med Sci Sports Exerc 1994;26:1319–26.
training have shown that the decrease in the V ~ O2 3 Whipp BJ, Ozyener F. The kinetics of exertional oxygen uptake:
assumptions and inferences. Med Sport 1998;51:139–49.
slow component at the same absolute intensity (90% ~O2max and its time
4 Billat V, Koralsztein JP. Significance of the velocity at V
vV~ O2MAX) is not correlated with an improvement in to exhaustion at this velocity. Sports Med 1996;22:90–108.
5 Brooks GA. Anaerobic threshold: review of the concept and direction for
performance (endurance time) at this velocity (+ 40% of future research. Med Sci Sports Exerc 1985;17:31–5.
6 Monod H, Scherrer J. The work capacity of synergy muscular groups. Ergo-
time limit). nomics 1965;8:329–38.
A more interesting fact about this V ~ O2 slow component 7 Housh DJ, Housh TJ, Bauge SM. The accuracy of critical power test for
phenomenon is for training at V ~ O2MAX as it creates a broad predicting time to exhaustion during cycle ergometry. Ergonomics 1989;32:
997–1004.
range of exercise intensities for which V ~ O2MAX will occur, 8 Jenkins DG, Quigley BM. The Y-intercept of the critical power function as a
measure of anaerobic work capacity. Ergonomics 1991;34:13–22.
provided that the exercise is continued to the point of 9 Gaesser GA, Poole DC. The slow component of oxygen uptake kinetics in
exhaustion.9 humans. In: Holloszy JO, ed. Exercise sport science review. Baltimore:
Williams & Wilkins, 1996:35–70.
Hence, it may be possible to describe a new relation 10 Barstow TJ, Molé PA. Linear and nonlinear characteristics of oxygen uptake
between time spent at V ~ O2MAX (tlimV ~ O2MAX) and velocity kinetics during heavy exercise. J Appl Physiol 1991;71:2099–106.
as a percentage of the velocity associated with V ~ O2MAX 11 Walsh ML. Possible mechanisms of oxygen uptake kinetics. Annals of
Physiological Anthropology 1992;11:215–23.
determined in an incremental test (vV ~ O2MAX). The 12 Whipp BJ, Wasserman K. Oxygen uptake kinetics for various intensities of
relation between time to exhaustion at V ~ O2MAX and constant-load work. J Appl Physiol 1972;33:351–6.
13 Billat V, Richard R, Binsse VM, et al. V~O2 slow component for a severe exer-
velocity follows a function that has a peak around cise depends on type of exercise and is not correlated with time to fatigue.
100% vV ~ O2MAX in well trained runners who have no, or J Appl Physiol 1998;85:2118–24.
14 Poole DC, SchaVartzik W, Knight DR, et al. Contribution of exercising legs
only a low value for, the V ~ O2 slow component (<200 to the slow component of oxygen uptake kinetics in humans. J Appl Physiol
ml/min). In less well trained subjects, the V ~ O2 slow 1991;71:1245–53.
15 Willis WT, Jackman MR. Mitochondrial function during heavy exercise.
component means that they spend longer sustaining Med Sci Sports Exerc 1994;26:1347–54.
~ O2MAX at 90% vV
V ~ O2MAX than at 100% vV ~ O2MAX.23 25 26 16 Holloszy JO, Coyle EF. Adaptation of skeletal muscle to endurance exercise
and their metabolic consequences. J Appl Physiol 1984;56:831–8.
However, fit endurance athletes have to run at close to 17 Hoppeler H. Exercise-induced ultrastructural changes in skeletal muscle. Int
100% of vV ~ O2MAX to elicit V~ O2MAX because they have no J Sports Med 1986;7:187–204.
18 Yoshida T, Udo M, Ohmori T, et al. Day-to-day changes in oxygen uptake
~ O2 slow component.23 24
V kinetics at the onset of exercise during strenuous endurance training. Eur J
Therefore, in training, if the aim is to elicit V ~ O2MAX, it Appl Physiol 1992;64:78–83.
19 Berry M, Moritani T. The eVects of various training intensities on the kinet-
may be useful to determine the velocity for which time ics of oxygen consumption. J Sports Med Phys Fitness 1996;22:90–108.
spent at V ~ O2MAX is maximal.25 To determine at which 20 Casaburi R, Storer TW, Ben-Dov I, et al. EVect of endurance training on
possible determinants of V ~O2 during heavy exercise. J Appl Physiol
velocity the longest time at V ~ O2MAX is obtained during con- 1987;62:1533–8.
Leaders 85

21 Gaesser GA. Influence of endurance training and catecholamines on 25 Billat V, Slawinski J, Bocquet V, et al. Intermittent runs at V~O2max enables
exercise V~O2 response. Med Sci Sports Exerc 1994;26:1341–6. subjects to remain at V~O2max for a longer time than severe submaximal run.

Br J Sports Med: first published as 10.1136/bjsm.34.2.81 on 1 April 2000. Downloaded from http://bjsm.bmj.com/ on October 11, 2019 by guest. Protected by copyright.
22 Womack CJ, Davis SE, Blumer JL, et al. Slow component of O2 uptake dur- Eur J Appl Physiol 2000;81:188–96.
ing heavy exercise: adaptation to endurance training. J Appl Physiol 26 Billat V, Blondel N, Berthoin S. Determination of the velocity associated
1995;79:838–45. with the longest time to exhaustion at maximal oxygen uptake. Eur J Appl
~O2
23 Billat V, Binsse V, Petit B, et al. High level runners are able to maintain a V Physiol 1999;80:159–61.
steady state below V ~O2max in an all-out run over their critical velocity. Arch 27 di Prampero PE. The concept of critical velocity: a brief analysis. Eur J Appl
Physiol Biochem 1998;106:38–45. Physiol 1999;80:162–4.
24 Jacobsen DJ, Coast R, Donnelly JE. The eVect of exercise intensity on the 28 Margaria R, Mangili F, Cuttica F, et al. The kinetics of the oxygen
slow component of V ~ O2 in persons of diVerent fitness levels. J Sports Med consumption at the onset of muscular exercise in man. Ergonomics 1965;8:
Phys Fitness 1998;38:124–31. 49–54.

Should nasal fractures be treated on the spot?

We all know the scenario at the side of the side. But not a ‘bag man’ pitch side or a
rugby pitch, as the team attendant or doctor casualty SHO (even after an x ray) to do the
yanks a nose straight before any pain is per- same procedure.”
ceived by a front row “beauty” who then “Bleeding following repositioning is unpre-
returns to play. But should nasal fractures be dictable and it should be done in a hospital
treated in this way, on the spot? environment by an ENT colleague.”
“Yes I would let an ENT colleague, GP or
Would sports medicine doctors let their first aid/bag man put my nose back pitch
own broken noses be treated on the spot? side as I don’t think x rays are necessary for
“Yes, I’d have it put back pitch side—once nasal fractures.” (Personal correspondence
I’ve retaliated and before the pain starts.” with ENT surgeons in Scotland)
“Depends who by.” The Defence Unions referred to the
“Yes I’d like it put back immediately . . .but Bolam Defence of “accepted practice” for a
I’ve had my nose put back on the field several sports doctor. “If a member were to treat a
times and then had to have a surgeon sort it displaced nasal fracture on the spot, and
all out later, but that’s OK.” (Personal there was an unsatisfactory outcome, it may
discussions at the BASM 1999 conference) well be alleged that it was negligent to
undertake such a procedure. In defending a
What are the dangers of this procedure? member we would need to take into account
If looks are spoilt, an athlete may be the training and experience of the member
persuaded to sue who ever tampered with and an independent expert opinion from a
their nose and make the culprit pay for their practitioner in the same speciality.” (Per-
private plastic surgery and loss of modelling sonal correspondence with The St Paul
career. Worse still would be the scenario of International Insurance Agency).
an underlying cribriform plate fracture (and “Advocates of an on the spot treatment of
possible other complications) being further nasal fractures would have to show good
disrupted by incompetent attempts at nasal supporting evidence that the outcome is at
fracture reduction or uncontrollable bleed- least as good, if not improved, by undertak-
ing of the nose pitch side and miles from ing urgent reduction, rather than waiting for
help. ENT specialist care a few days after the
injury.” (Personal correspondence with the
Some questions before letting the doc Medical Defence Union).
sort the nose My search for what is accepted practice
Is the heat and pressure of the sports field the for “on the spot” treatment of nasal
place to be deciding the severity of the frac- fractures proved fruitless!
ture even if you are a doctor? In conclusion, I think that until “What is
How much ENT training has the average accepted practice for sports medicine doc-
sports doctor had? tors” is tested in a court of law, we are still
Would an ENT surgeon reduce a fracture left with no straight answer to the question.
pitch side? In simple terms, individual doctors must ask
Would an ENT surgeon be happy for themselves whether they are competent to
doctors, physiotherapists, or first aiders to undertake the procedure.
reduce a nasal fracture “on the spot”? First aiders are covered by the Good Samari-
ENT surgeons’ opinions varied among tan Act of 19831 to administer first aid
those I contacted. according to the accepted practices and
“Allowing a GP colleague, if experienced, or manuals of the voluntary first aid societies;
ENT surgeon to put their nose back pitch this does not include reducing nasal fractures.
JANE DUNBAR
Dunblane, Scotland
1 Mod Law Review 1990:53.
Br J Sports Med 2000;34:315–318 315

that measures directed towards the extrinsic We have conducted a three year prospec-
causes of sports injuries (for example, tive controlled study that linked diagnostic
LETTERS TO problems with the rules or with personal and ultrasonography data to clinical presentation/
playing area equipment) are often the most symptoms. The results showed a strong
THE EDITOR eVective ways of reducing the incidence of correlation between the ultrasound findings
sports injuries. Furthermore, a number of and the clinical markers used, such as pain,
studies have failed to show that warm up and stiVness, and functional ability.
high levels of flexibility are eVective in reduc- To conclude, ultrasound is a useful and I
ing the incidence of sports injuries. believe an eVective tool to aid in the diagnos-
Survey of sports injury prevention Because of the low response rate the find- tic process to evaluate tendon pathology.
programmes in the European ings of our survey must be regarded as However, it is only part of the process and, in
Community preliminary. However, they do suggest the isolation, can be as misleading as it is helpful.
following: DAVID CHAPMAN-JONES
EDITOR,—I would like to provide a brief 1. A significant number of sporting organis- 3 Monastery Avenue, Dover, Kent CT16 1AB,
report of a survey of sports injury prevention ation are ignoring the problem of sports United Kingdom
programmes and related research projects in injuries.
the European Community between Septem- 2. Injury prevention programmes are often
1 Khan K, Kannus P. Use of imaging data for pre-
ber and December 1998. not based upon good empirical evidence dicting clinical outcome. Br J Sports Med
With the cooperation of partners in the and frequently do not address the risk fac- 2000;34:73.
tors specific to particular sports. 2 Kannus P, Jozsa L. Histopathological changes
Netherlands (the Netherlands Olympic preceding spontaneous rupture of a tendon. J
Committee and the Netherlands Sports Fed- 3. Quality control and follow up measures Bone Joint Surg [Am] 1991;73:1507–25.
eration), Austria (the Austrian Institute for are rare in the context of injury prevention
Home and Leisure Safety), and Belgium programmes.
(Flanders Red Cross) a questionnaire on 4. The lack of appropriateness and eVective- Denial of mental illness in athletes
sports injury prevention and related research ness of some injury prevention pro-
was devised, piloted, and distributed to a grammes is being noticed by athletes and EDITOR,—Professor Schwenk makes the im-
sample of 368 sports, health, or safety sports administrators. portant point that elite athletes are not
organisations in Europe. The objective of the Notwithstanding the limitations of our immune to serious mental illness and that
study, I find the results a source of concern. I many of the symptoms of overtraining may, in
study was to determine the number of
would urge your readers to impress upon another context, be considered diagnostic of
institutions involved in injury prevention
sporting organisations the need to take injury depression.1
work, and also to seek information on the
prevention seriously, and to do all they can to I have usually considered the following to
nature and quality of the work being
ensure that the measures adopted are based be a helpful diVerentiator between the two
undertaken.
upon the results of empirical research, and conditions. Patients with depression will
A total of 86 questionnaires were returned
that quality control measures are put in almost always resist any suggestion that they
from 77 diVerent organisations in 28 Euro-
place. may be more physically active. In contrast,
pean countries. The largest number of
the complaint of the athlete with what has
returns was received from Austria (13 A W S WATSON been termed either overtraining or the
returns), Belgium (9 returns), Ireland and the Sports Injuries Research Centre,
University of Limerick,
chronic fatigue syndrome will usually be that
Netherlands (7 returns), and Finland, Ger- they desperately wish to exercise. However,
many, and Norway (6 returns each). 87% of Limerick,
Ireland whenever they do exercise, they become pro-
the organisations responding to the survey foundly fatigued such that the exercise is not
were involved primarily in either sport, safety, pleasant and further compounds their state of
or education and research. The other 13% chronic fatigue.
1 Renstrom PAFH, editor. Sports Injuries: basic
provided health care services. principles of care and prevention. Oxford: However, after reading Professor Sch-
Forty two out of 86 respondents (58.8% of Blackwell, 1993. wenk’s article, it struck me that, as fatigue is
the returns and 11.2% of the total question- 2 Watson AWS. Sports injuries: incidence, causes,
prevention. Physical Therapy Reviews 1997;2: a symptom that is perceived centrally in the
naires distributed) reported that they were 135–51. brain, it may be that this distinction is not as
currently running a programme on sports clear cut as one may conclude. Could exercise
injury prevention or related research. Less intolerance, as opposed to exercise avoidance,
satisfactorily, only 14 of the injury prevention Use of imaging data for predicting be a symptom of depression in elite athletes?
projects (16.3% of those responding and clinical outcome
3.8% of the original sample) were based upon TIMOTHY D NOAKES
research data or had any kind of inbuilt qual- EDITOR,—I write with reference to the letter Discovery Health Chair of Exercise and Sports Science
and Director MRC/UCT Bioenergetics of Exercise
ity control mechanism (such as an assessment of Khan and Kannus.1 I concur that Gibbon
Research Unit University of Cape Town, South Africa
of the eVectiveness of the programme). and colleagues are not in a position to draw a
Respondents were also requested to send in conclusion on the diagnostic ultrasound
examples of their injury prevention materials screening of athletes suggesting that sono- 1 Schwenk TL. The stigmatisation and denial of
and to provide comments on the provision of graphic abnormality will lead to a complete mental illness in athletes. Br J Sports Med
2000;34:4–5.
injury prevention programmes in their sport. rupture. However, I also do not fully agree
Many of the programmes were found to con- with the authors of the letter that tissue based
sist only of warm up and stretching exercises; pathologies found by Kannus and Jozsa2 may
these were often poorly described and of be more subtle than can be detected by
doubtful value. Few of the programmes were sonography.
supported by empirical evidence or ad- To explain, I feel that part of the problem, BOOK REVIEWS
dressed risk factors specific to individual resulting in this divergence of opinion, lies
sports. both with the diversity of the diagnostic
Some of the comments returned with the ultrasound equipment used and the skill of
questionnaires included the following: the operator. There is little standardisation of
+ “This questionnaire is not relevant to us. either of the techniques used by operators or, Facilitated stretching. 2nd ed. Robert E
Our members look after their own inju- in particular, equipment specification. To this McAtee, JeV Charland. (Pp 143; soft cover;
ries.” end, articles that report studies correlating £13.95.) Leeds: Human Kinetics Europe
+ “There are hardly any injuries in our diagnostic ultrasound findings with other Ltd, 1999. ISBN 0-7360-0066-6.
sport.” (A sport known to produce a mod- clinical markers have to be carefully inter-
erately high incidence of overuse injuries.) preted. This is the second edition of a book
+ “Injury prevention measures don’t work.” Colleagues and I have been regularly previously published in 1996 which has been
+ “Stretching and warm up are a waste of performing musculoskeletal ultrasound ex- reorganised to make it easier to use and
time.” aminations, particularly on Achilles and broaden the scope of stretches presented.
Reviews of the literature on sports supraspinatus tendons. We regularly visualise Chapter 1 begins with the historical basis
injuries1 2 show that injury prevention meas- degenerative changes in asymptomatic ten- of PNF, discussing the work of Kabat and
ures are most eVective when directed at par- dons that do not go on to rupture or produce later Knott and Voss. It then goes on to
ticular sports and population groups, and significant problems. explain the myotactic stretch reflex and the

www.bjsportmed.com
316 Letters, Book reviews, Symposium report, Notes and news, Calendar of events, Correction

role of muscle spindles, together with the role Analysis problems associated with boxing and what
of the Golgi tendon organ in the inverse Presentation 15/20 evidence there is to confirm how they
stretch reflex (autogenic inhibition) and its Comprehensiveness 15/20 occurred. It is pointed out that there is a lack
function in Chaitow’s muscle energy tech- Readability 17/20 of well controlled studies of boxing injuries.
nique, where muscle elongation takes place Relevance 17/20 The Johns Hopkins Medical Institute study
during “post-isometric relaxation”. Evidence basis 13/20 of central nervous system function in amateur
Chapter 2, “Stretching basics”, skims over Total 77/100 boxers is a linear prospective investigation,
the subject of whether it is necessary to IAN HORSLEY which was reported by two of the team in the
Lecturer in rehabilitation studies chapter discussing the risk of brain damage.
stretch. Although it is admitted that there is
University of Salford Initial findings (1994) of impaired cognitive
no clear agreement of the value of stretching,
function being related to the number of pre-
personally I would have liked to have seen
vious bouts but reported as being not
quoted some references both for and against HIV/AIDS in sport. Impact, issues and
clinically significant needs further elucida-
stretching. Again in this chapter the ideal sce- challenges. G Sankaran, K A E Volkwein, tion, and follow up results should be interest-
nario is stated “stretch after warming up, D R Bonsall. (Pp 137; soft cover; £21.50.) ing.
exercise, then stretch again after exercise as Leeds: Human Kinetics Europe Ltd, 1999. The editor points out that safety changes
part of the cool-down process” but then this ISBN 0–88011–749–4. have been made in American football, profes-
is followed by “If time is a factor . . . we rec- sional boxing, and, in particular, amateur
ommend skipping the pre-exercise stretching The complexity of the issues surrounding boxing through informed medical advice. He
and concentrate on the post-exercise stretch- HIV and AIDS in sport is dealt with in a con- would like to see the safety and preventive
ing.” As a physiotherapist, I would advise the cise yet comprehensive manner in this book. medicine aspects of the amateurs incorpo-
opposite—that is, stretch before exercise—as The issues range from epidemiology and rated into the professional world, and the
I feel this helps to reduce injury. This apart, immunology of HIV to ethical and legal mat- final chapter of the book is an excellent
ters. The chapter dealing with the basic account of how professional boxing could be
the rest of the chapter is well written and
science of HIV was informative and yet writ- made safer. Measures are outlined with
briefly considers several diVerent types of ten in such a way as to be within the grasp of
stretching, concluding with a detailed de- reasons why they are necessary.
someone not in that field. A similar section The IOC medical commission does not
scription of how to carry out the techniques dealing with exercise and immune function
for both therapist and subject, emphasising now permit theophyllines and systemic ster-
was well covered, and I agree with the oids, which are suggested as permissible for
the importance of positioning to minimise the conclusion that more work should be carried asthma treatment. Otherwise the role of the
risk of injury to both, and how to isolate indi- out in this particular area. Personal accounts ringside doctor is extremely detailed, com-
vidual muscles. of both amateur sports people and inter- prehensive, and includes an excellent account
The final section of part I describes national sport stars were insightful, but of safety measures that need to be present.
patterns of movements for both upper and lacked depth and skimmed the surface of the Boxing is an extremely contentious subject,
lower limbs with useful black and white pho- full implications in this diYcult area. How- but this book will be of interest to any sports
tographs to assist with understanding. ever, these may lie beyond the scope of such physician involved in boxing or who at least
Part II of the book contains the stretches a broad ranging book. The chapters dealing wishes to be able to take part in reasoned
and is divided into chapters on stretches for with legal and ethical issues were, on the debate.
the lower extremity, upper extremity, torso, whole, diYcult to read and perhaps not
geared for the layman. The helplines would Analysis
and neck. The general layout begins with the
only really be appropriate to readers living in Presentation 17/20
anatomy of the muscle group, accompanied
the United States. This and the high price are
by a line drawing, a table that shows origin, Comprehensiveness 17/20
the only criticisms I have of a neat and well
insertion and action, and functional assess- Readability 16/20
presented book that is bound to become well
ment, showing normal ranges of movement. Relevance 18/20
thumbed by those in the field.
The stretches are then described with rel- Evidence basis 17/20
evant photographs showing the positions of Analysis IAN MCGIBBON
subject and partner. Finally there is a “self Presentation 15/20
Kircudbright
stretch,” with description and black and Comprehensiveness 15/20
white photograph. Readability 12/20
The final chapter in part II is entitled Relevance 18/20
“PNF in physical therapy” and diVers from Evidence basis 15/20
the previous section of the book, as it deals
with treatment of injury and the role of PNF
Total
BRENDON MURPHY
75/100
SYMPOSIUM
in rehabilitation, providing case presentations
and treatment programme.
Final Year PhD student,
Department of Immunology,
REPORT
In a literature review in the appendix it St Barts and Royal London Hospitals,
London EC1A 7BE, UK
states that “eight of the fourteen studies
reviewed (57%) found that PNF stretching is
significantly more eVective for increasing Boxing and medicine. Ed R C Cantu. (Pp Symposium on football medicine
ROM and flexibility than static, ballistic or 207; £28.50.) Leeds: Human Kinetics
passive stretching” but does not provide suf- Europe Ltd, 1995. ISBN 0-87322-797-2. This one day symposium took place at Liver-
ficient information for one to read these pool Medical Institution on 16 March 2000.
studies and compare the protocols used. I enjoyed reading this book. A book consist- A total of 65 delegates from the whole
Furthermore the number of references ing solely of accounts of boxing related inju- spectrum of sports physicians, surgeons, and
used throughout the book is comparatively ries would probably have been a chore to read therapists across the United Kingdom at-
small considering the wealth of studies and reinforced my prejudices about a pastime tended, in addition to local general practi-
now being published on the subject of in which participants have to punch their tioners.
flexibility. opponents to score points. However, this is a Mr Steve Bollen debated the management
well balanced book that sets out the medical of ankle ligament injuries; a sound evidence
Overall I feel the book is well written and
aspects of boxing in a logical fashion. basis substantiated his conclusion that, al-
informative supported by good drawings and
The diVerences between amateur and though surgery for chronic instability and
photographs. My only reservation is the professional boxing are explained, and there pain does aVord good results, operative inter-
cover of the book. Although the second edi- are chapters that address the ethical and vention has little place in the acute manage-
tion has been published this year, the social aspects of the sport in America. Robert ment of even a grade three injury.
colours, style of presentation, and photo- Cantu, the editor, a past president of the Professor David Chadwick reported on the
graphs give the impression that the book American College of Sports Medicine and latest Australian data from the Victorian
belongs in the 1970s! Notwithstanding this, I medical director of the National Centre for State Injury Surveillance System, and the
feel the book will be of great value to every- Catastrophic Sport Injury Research, has concept of “convulsive convulsions” was dis-
one working within the field of rehabilitation overseen contributions from a number of cussed. He suggested that the second impact
and sports injury. eminent people. Experts look at the medical syndrome may be a myth, as it is not reported

www.bjsportmed.com
Letters, Book reviews, Symposium report, Notes and news, Calendar of events, Correction 317

in certain sports such as boxing where it RCGP sport and exercise medicine working short essay paper will be held in April and
might be expected. group, BASEM, and NSMI. Any individual September in London, Glasgow, or Dublin.
Professor Wayne Gibbons demonstrated who wishes to make their views known can Successful candidates will proceed to part 2 of
the use of ultrasound—as scanners become contact any of these groups or may wish to the examination in either June or November.
cheaper they could be used for “near-patient contact Nick Harrison at the BMA on 020 This consists of an oral and a clinical, based
testing”. The demonstration on MRI chal- 7383 6225 or nharrison@bma.org.uk. on two OSCEs, and will be held at a single
lenged anatomy textbooks, in particular, the centre which will rotate every six months
existence of the conjoint tendon which may Further details: Examinations Department,
be an embalming artefact. Stimulated by the articles on education Royal College of Surgeons in Edinburgh,
Dr John Hunter’s presentation on the in this issue? Nicolson Street, Edinburgh EH8 9DW.
“EVects of exercise on the gut” included jog- The School of Postgraduate Medical and Website: www.rcsed.ac.uk
gers’ diarrhoea, and it seems that it is not a Dental Education at the University of Wales
general eVect of exercise, but certain people College of Medicine (UWCM) recently
such as the young and poorly trained may be advertised their Diploma/MSc in Sports 2000 Pre-olympic scientific
more susceptible. Medicine. The purpose of this course is to congress
Mr David Rees from the Elite Sports educate doctors and chartered physiothera- 7–13 September 2000; Brisbane, Australia
Assessment Centre showed the facilities and pists who wish to develop their expertise in Themes running through the programme
techniques used at their sports injuries labo- sports medicine. It will be organised prima- include:
ratory in Oswestry. In particular, anterior rily as an open distance learning programme + Role of the Olympic Games in promoting
cruciate ligament rehabilitation and assess- and is PGEA approved. The cost is £1800 for health for all
ment was discussed. national students and £3585 for international + Impact of elite athlete sports medicine on
The symposium concluded with Professor students. Further details are available from the general community
Klenerman discussing foot and ankle injuries. Mr Gareth Irwin, University of Wales Insti- + Ethical issues and ergogenic aids
Early controlled mobilisation was preferred tute, CardiV, Cynoed Road, CardiV + Sports medicine, sports science, and
to immobilisation in plaster after Achilles CF23 6XD; tel: 0292 041 6537; email: physical activity in the new millennium
tendon repair. Girwin@uwic.ac.uk. + Funding of elite sports versus physical
STEVE McNALLY education
General practitioner and Medical OYcer to + Regional issues and developing countries
Liverpool FC Academy BASEM 2000 conference + Sport for whom? Nations, corporations,
There is already considerable interest in the spectators or athletes?
BASEM 2000 conference in Tewkesbury on + Manipulating athletic bodies: science,
3–5 November. The congress continues to training, technology, and drugs in the 21st
develop and the combination of outstanding century.
NOTES AND NEWS international speakers, the very best of
research from the UK, and a vibrant social
Further details: Congress Manager, Sports
Medicine Australia, PO Box 897, Belconnen
programme ensures its continued success. Act 2616, Australia. Tel: +61 2 6251
The current interest and controversies sur- 6944. Fax: +61 2 6253 1489. Email:
rounding the management of head injury in smanat@sma.org.au
Annual meeting of the American sport will attract considerable academic and
College of Sports Medicine media interest when Dr Bob Cantu, one of
the leading researchers from the USA, 19th congress of sports medicine
A large contingent from the UK travelled to addresses this topic on the afternoon of
the annual meeting of the American College 13–14 October 2000; Bruges, Belgium
Saturday 4 November. Our other keynote Topics include:
of Sports Medicine. Nic Mafulli gave the speaker, Professor Norbert Bachl from Aus-
annual BASEM lecture to a select group of + Sports physiotherapy
tria, promises a fascinating lecture on the + Children and sports
tendon experts, and many other prominent eVect of living on Space Station Mir. We
BASEM members gave important presenta- + Arthroscopy and sports traumatology
also look forward to hearing about + Medical ethics, doping, and sports
tions. The number of UK participants at this European developments in sport and exer-
meeting has increased greatly and already a Further details: Dr Michel D’Hooghe, Presi-
cise. Further details are available from Mrs dent Brucosport, Hospital AZ Sint-Jan AV,
number of research groups are planning to Sue Roberts, BASEM Company OYce, 12
contribute to next year’s meeting in Balti- Ruddershove 10, B-8000 Brugge, Belgium.
Greenside Avenue, Frodsham, Cheshire Tel: +32 50 452230. Fax: +32 50 452231.
more. WA6 7SA. Tel: 01928 732 961; email: Email: brucosport@azbrugge.be
basemoYce@compuserve.com. Website: http://user.online.be/brucosport/
Guidelines for advising on injury index.htm
treatment and prevention
There is increasing awareness in the sporting
and medical community of the need for 1st Moscow International Forum:
medical input in injury treatment and preven- CALENDAR OF Sport medicine science and
practice on the eve of the 21st
tion. The British Medical Association is cur-
rently considering the need to issue guide- EVENTS century
lines to doctors who may be acting, or 20–25 October 2000; Moscow
interested in acting, as a medical advisor to Further details: Organising Committee of the
sports clubs or at other public events in a vol- Forum, Yachshuk AM, Zemlyanoi Val 53,
untary, rather than a professional full time Moscow. Tel: +7 928 29 92
capacity. It is envisaged that the issues British Association of Sport and
covered would include reference to the Exercise Sciences Annual
courses run by the Football Association, the Conference Symposium: training,
National Sports Medicine Institute, and any 29 August–1 September 2000; Liverpool, UK
other relevant organisations. Such issues as Further details: BASES 2000, Event Manage-
overtraining, and regeneration in
insurance, responsibilities of the doctor, rela- ment Services, Egerton Court, 2 Rodney St, sport—from the muscle to the
tionship with competitors’ GPs, legal and Liverpool L3 5UX. Tel: 0151 231 3585. Fax: brain
contractual arrangements, responsibility for 0151 709 5057. Email: ems@livjm.ac.uk 26–28 October 2000; University of Ulm,
crowd injuries, and the need for knowledge of Germany
injuries specific to the sport/event would be Topics include:
covered. It is likely that any guidelines issued Diploma in Sport and Exercise + Training and regeneration in sports
would appear on the BMA website with links Medicine, Great Britain and + Metabolism, training, and monitoring
to other organisations and would be sent to Ireland + Cellular protection and immunological
interested doctors. The British Medical This two part diploma examination will be function
Association has consulted with a number of held twice a year. Part 1 of the examination, + Muscular adaptations and stress proteins
bodies about the guidelines, including the consisting of a multiple choice question and and cytokines

www.bjsportmed.com
318 Letters, Book reviews, Symposium report, Notes and news, Calendar of events, Correction

+ Peripheral mechanisms for adaptation and Further details: Pranacom, 40 rue des Blancs True or false?—answers
regeneration Manteaux, 75004 Paris, France. Email: (T = true; F = false)
+ Hypothalamic hormonal regulation and pranacom.ifrance.com p 246: Pedersen BK, Toft AD. Exercise
the central nervous system Website: www.sfms.asso.fr eVects on lymphocytes and cytokines
Further details:Dr J M Steinacker, Abt. Sport
(1) T; (2) F; (3) T; (4) F; (5) F.
and Rehabilitationsmedizin, Medizinische
Klinik und Poliklinik, Universitätsklinikum
Ulm, 89070 Ulm, Germany. Tel: +49 731 Essay question—answer
502 6966; fax: +49 731 502 6686; email:
NSMI/BASEM Current concepts
p 246: Pedersen BK, Toft AD. Exercise
org.sportmed@medizin.uni-ulm.de meeting on tendinopathies eVects on lymphocytes and cytokines
Website: www.uni-ulm.de/sportmedizin 8–9 December 2000; Cambridge, UK Exercise induces increased levels of cy-
Subjects covered include: tokines in the blood. The levels of TNF, IL-1,
+ Tendon science IL-6, IL-1ra, IL-8, IL-10, MIP-1â and
+ Achilles tendon sTNF-R increase. IL-6 increases more than
British Association of Sport and + Rotator cuV any other cytokine, the increase being up to
Medicine congress Further details: Barry Hill, NSMI Medical 100-fold that measured at rest.
3–5 November 2000; Tewkesbury, UK Education, Medical College of St Bartholo-
Lectures include: mew’s Hospital, Charterhouse Square, London
+ Muscular conditioning during space sta- EC1M 6BQ. Tel: 020 7251 0583 x237; fax:
tion MIR flight 020 7251 0774; email: barry.hill@nsmi.org.uk Multiple choice—answers
+ Health enhancing physical activity—an Website: www.nsmi.org.uk p 252: Rath E, Richmond JC, The menisci:
upgrowing challenge for sports medicine basic science and advances in treatment
Further details: Mrs Sue Roberts, BASEM
Company OYce, 12 Greenside Avenue, 1 (e); 2 (c); 3 (a); 4 (c); 5 (b).
Frodsham, Cheshire WA6 7SA. Tel/fax:
01928 732 961; email: basemoYce@ Essay questions—answers
compuserve.com
Website: www.pmhcs.com/basem
CORRECTION p 252: Rath E, Richmond JC. The menisci:
basic science and advances in treatment.
1 This patient might present with recurrent
20th national congress of the joint line pain, episodic swelling, clicking.
The authors of Khan et al (BJSM Often there will be no or trivial trauma.
Société Française de Médicine de Physical examination may disclose an eVu-
Sport: Physical activity, sport and 2000;34:81–83) have conceded an
error. They referred to patellar tendon sion, with joint line tenderness, and pain
health on forced flexion.
allograft instead of patellar tendon autograft,
6–8 December 2000; Paris, France 2 The meniscus serves several important
and regret any confusion they may have
Topics include: functions, most notably force distribution
caused.
+ Physical activity and fertility and joint surface protection. Preserving
+ Sport and aging healthy meniscal tissue will reduce the long
+ Rehabilitation term risk of osteoarthrosis.

www.bjsportmed.com